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Incident Investigations

Assessment of Chemical Exposures (ACE) Program

When chemical releases happen suddenly, ATSDR can provide local authorities with valuable help through the ACE program.

In June 2011, after a chemical incident at a poultry processing facility, 600 workers were potentially exposed to chlorine, 170 of whom needed transportation to five area hospitals for medical evaluation. The state Department of Health asked ATSDR to assist in the investigation of the incident, including an evaluation of the emergency response. An ACE team was deployed in response. The team discovered that the state Department of Emergency Management was not required to notify the health department when the incident occurred. This resulted in missed opportunities for assistance, such as coordinating with local hospitals regarding where patients were transported for care or providing treatment protocols for chlorine gas.

After the ACE investigation identified the issue, the Department of Emergency Management modified their procedure for notification of the state health department to include any incident involving a biological, chemical, radiological, or nuclear substance. About two weeks after the procedures were modified, two different ammonia releases occurred in the same city as the previous release. Because of the new procedures, emergency management officials immediately notified the health department of the incidents, resulting in a more coordinated and effective response.

What is ACE?

When toxic substance spills or chemical emergencies happen, ATSDR helps state and local health departments by providing ACE resources to perform a rapid epidemiologic assessment.

What resources does ACE provide?

ACE provides training on how to perform an epidemiologic assessment after a chemical incident. The ACE Toolkit is a helpful resource to assist local authorities in responding to or preparing for a chemical release. The toolkit contains materials that can quickly be modified to meet the needs of a local team performing an epidemiologic assessment, including:

Surveys

Consent forms

Medical chart abstraction form

Interviewer training manual

Epi Info™7 databases to enter and analyze the data

When an incident occurs ACE provides technical assistance by forming a multi-disciplinary, often multi-agency, team to assist the state and local health department. Team members may assist from ATSDR headquarters in Atlanta, Georgia or deploy to the scene.

Other support the ACE team can provide is:

GIS mapping and assistance with sample methodologies

Clinical testing, if appropriate

Liaising with other federal agencies

What happens during an ACE investigation?

ACE talks with incident responders and hospital staff that treated patients to understand

what happened,

who was exposed,

steps taken to protect public health, such as an evacuation or shelter-in-place order,

communication during the response, and

lessons learned during the response.

ACE also interviews people who may have been exposed to collect detailed information on

exposure history,

symptoms experienced,

who was exposed,

health services used,

needs resulting from the exposure,

medical history,

how people received information about the release, and

health impacts on pets.

ACE typically reviews hospital medical charts and veterinary chart abstractions to learn more details about health effects experienced as a result of the release. ACE may also assist in collecting and analyzing clinical samples if a laboratory test is available to determine exposure to the substance. If testing is done, results are sent to participants to share with their physicians.

Why perform an ACE investigation?

State and local health departments can use information obtained from rapid assessments to

assess impact of the release on individuals as well as the community,

direct the public health response,

target outreach to prevent similar incidents,

assess the need to modify emergency response procedures, and

identify a group of exposed people that may need to be followed-for long-term effects.

A body of data from multiple incidents can be used for education and training to prepare for future incidents.

What are some examples of ACE investigations?

The ACE team worked with the state or local health agency on the investigations and public health actions described below. Additionally, ATSDR has partnered with other public health and safety agencies, like the National Institute for Occupational Safety and Health (NIOSH) to work on chemical releases. The goals of each investigation were determined by the inviting agency. Each investigation involved multiple components, including interviewing responders and owners/managers of facilities, surveying exposed persons and staff at hospitals where patients were treated, and reviewing hospital charts for patients treated for chemical exposure.

Chlorine release at a metal recycling facility
Chlorine gas was released when a 1-ton, low-pressure tank was cut at metal recycling facility. Most workers and customers followed the planned evacuation route, exiting the facility through the main gate and meeting in an open field that was downwind from the tank. The ACE team, working with the state and local health department:

Interviewed responders and facility owners, surveyed exposed persons, and the state partners abstracted hospital charts. A report of the investigation has been published.

Only accept containers that are cut open, dry, and without a valve or plug.

Treat closed containers as potential hazardous waste.

Develop and practice an evacuation plan. Train workers to stay upwind when evacuating for a chemical release.

The state health department conducted follow-up interviews and medical record review of the affected workers 6 months after the incident, determining that some workers had ongoing respiratory and psychological symptoms. As a result of their findings, they provided technical assistance to the treating providers.

Ammonia release at a refrigeration facility
A pipe ruptured on the roof of a refrigeration facility, releasing anhydrous ammonia. A cloud of ammonia drifted over a canal behind the facility, exposing personnel on ships docked at the refrigeration facility and at a large facility across the canal where work was taking place outdoors. The ACE team, in conjunction with the local health department and the state’s CDC Career Epidemiology Field Officer:

Interviewed personnel at the refrigeration facility, responders, and employees of a large facility that was downwind; surveyed exposed persons at the downwind facility; and reviewed hospital charts. County partners surveyed hospitals where patients were treated.

Participated in a Hotwash (after action review) of the response to the incident and reported that there was a lack of notification of the people in the area of the release. The county later obtained a reverse 9-1-1 system to be able to call telephones belonging to residents and businesses in a defined geographic area and deliver recorded emergency notifications.

Chlorine release at a poultry processing facility
A worker accidently mixed sodium hypochlorite with an acid-containing disinfectant, releasing approximately 40 lbs of chlorine gas within the facility. Due to the air flow within the building, workers were exposed both at their work stations and in a major hallway used as an evacuation route. The ACE team, assisting the state and local health department:

Partnered with NIOSH on the investigation. The NIOSH team performed a Health Hazard Evaluation at the facility and surveyed workers to learn their health effects.

Interviewed responders, surveyed staff at hospitals where patients were treated, and reviewed hospital charts of patients treated for chlorine exposure.

Determined that the existing emergency response protocols had an excessively high threshold for notification of the health department about chemical incidents. After the ACE investigation identified the issue, the notification protocol was modified to include health department notification of any incident involving a biological, chemical, radiological, or nuclear substance.

Vinyl chloride release from a train derailment
A tanker car punctured during a train derailment released approximately 24, 000 gallons of vinyl chloride on the edge of a small town. A shelter-in-place order was established for surrounding areas, then was lifted and reestablished repeatedly over four days, as vinyl chloride levels in the air fluctuated due to weather conditions. The ACE team, in partnership with the state and local health department:

Surveyed community members who were potentially exposed, surveyed staff from hospitals where patients were treated for vinyl chloride exposure, surveyed staff from a facility whose only access road was blocked by the derailed train, and performed hospital chart abstractions. State partners mailed a survey to all households in the community.

Partnered with a NIOSH team which interviewed representatives from responder groups and created a written survey for responders. A report of the NOISH investigation has been published.

Answered responders’ questions during their meetings and collected information needed to address community concerns.

4-Methylcyclohexanemethanol and propylene glycol phenyl ether contamination of a public water supply
A tank containing chemicals used in coal processing leaked into a river just upstream from the intake of the municipal water supply for approximately 300,000 people. A “Do not use” water order was issued for a nine-county area. The ACE team, working with the state health department:

Performed hospital chart abstractions for patients treated for exposure to the contaminated water. Surveyed area hospitals to learn of their experiences with the “Do Not Use” water order. A review of disaster epidemiology capacity within the inviting agency was also performed.

Used results from the hospital chart reviews for local outreach and education efforts in an effort to alleviate the public’s concerns about spill-related health effects. Findings of the hospital survey were used to provide information to hospitals planning for emergencies where their water supply is compromised. The disaster epidemiology capacity report was used to aid in planning for health department responses to future disasters.

How do we request ACE assistance or learn more about ACE?

ACE representatives can be contacted via phone and email. A representative can help local authorities determine what assistance is needed. If an ACE investigation—on-site field assistance—is appropriate, approval of the state epidemiologist must be secured. An ACE team can then be rapidly deployed to the field to provide assistance for up to 30 days. After leaving the field, the team continues working with the local authorities to analyze data and prepare reports.

ACE investigations will be carried out in the event of an acute chemical release of toxic substances, which can cause serious health effects. An event must involve:

the release of a toxic substance at levels that may cause acute human health effects

Assessment of Chemical Exposures Training

The Assessment of Chemical Exposures (ACE) training introduces how to perform an epidemiologic assessment after a chemical incident. It also describes the ACE Toolkit, which contains surveys, consent forms, databases, and training materials that are useful in responding to or preparing for a chemical release.